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FOR OFFICE,US,E: APPLICATION FOR SANITATION PERMIT Permit No. ------ ----------- (Complete in Triplicate) 11 ------------ /y-- ---- Date Is.sued 129-mac 4� This Permit Expires 1 Year From Date Issued Application is hereby made to the San Joaquin Local Health District for a permit to construct and install1the work herein described. This application is made in compliance with County Ordinance No. 549 and existing Rules an a Regulations: JOB ADDRESS/LOCATION .--------------------------- d�r -------- ------CENSUS TRACT - ; If ' - -- _Phone �--- ` ----------------------------------------------- Owner's Name = CitY - ------- Address � � ------------------------------- city Name ____ __ -- ---- --- ------------- -----•License # ��_��__ Phone -y----- Installation will serve: Residence ❑ Apartment House❑ Commercial:.Trailer Court i❑ Motel ❑Other ------ -- Number of living units_____________ Number of bedrooms ____________Garbage Grinder ----------- Lot Size - ----- � Water Supply: Public System and name ----------------------------------------------------------------------------------------------------------- ---------------------- - •----------IPrivate)<� F Character of soil to a depth of 3 feet: Sand❑ Silt❑ Clay ❑ Peat❑ Sandy Loam ❑ Clay Loam [IHardpan E] Adobe' Fill Material -___________ If yes, type ----- illi------- r i (Plot plan, showing size„of lot, location of system in relation to wells, buildings, etc. must be pli 11 on reverse side.) r NEW INSTALLATION: (No septic tank or seepage pit permitted if Public sewer is available within 200 feet,] < SEPTIC TANK Size_�%Z S.�! ---------------------- Liquid Depth ------------------�-- ------- [� PACKAGE TREATMENT [ ] I 4411,1 Capacity L G' - Type'�� Material_ 2 ------ No. Compartments i r b Distance to nearest: Well ____ - -----------------Foundation _/!�P------------- Prop:IlLine . ---�1.f I No. of Lines -----/---------------- Length of each line----1� ---------------- Total Length. - ----------------- LEACHING LINE [ ] D' Box ------------ Type Filter Material - '_ !�_/ Depth Filter Material _-1J?....-- ---- -- C Distance to nearest: Well --= -----------,; Foundation :--�///-------------- Property LEne l_� _.---------•--•-- SEEPAGE PIT [ ] Depth -.------. Diameter _ _ ------ Number __________L_________"If______ Rock Filled Yes ' ` No :❑ Water Table Depth ------��------------------------------ ---Rock Size __ __?�3----------.------ i ` f Distance to nearest: Well 1-0/i ------Foundation ___�-Q__--•--- Prop. Line .- ---_-. . ( REPAIR/ADDITION(Prev. Sanitation Permit# -------------------------------------------- Date -----------------.----------------) --------------------------- Septic Tank (Specify Requirements) ----------------- -------------------- -------------------------- ,.. - ---------------------------------------- - 1; - ----------------------- Disposal Field (Specify Requirements) ___-____.--- ---------------- - --------------------------------------------------------- --------------------- ------------- -- -- --- ------------------------------`-----=----------------- ---------------------------- ----------=--------------------------------------------------------------------------------------------------------------------------------- (Draw existing and required addition on reverse side) hereby certify that I have prepared this application and that the work will be`done in accordance::with San Joaquin County Ordinances, State Laws, and Rules and Regulations of the San Joaquin Local Health District. Home owner or licen- sed agents signature certifies the following: , "I certify that in the performance of the work for which this permit is issued, 1 shall not employ any person in such manner as to become subject to Wo kman's Compensation laws of California." b .0 -- OwnerSign -- --- T ------ ed - _1__ --------- (If other than owner) FOR DEPARTMENT USE ONLY APPLICATION ACCEPTED BY --lli�- '"� DATE I�1 ' BUILDING PERMIT ISSUED -------------------------- -------------------------------- DATE �M= ADDITIONALCOMMENTS -------------------------------------------------------------------------- -----------------------------------------P__A --------------------------------------------------------------------------------- - - gyp` )-01;0 �x---- j1:---- -------- ---------------- I _ 'E ---------------- ---------------------------------------------------------------------------------- - -- ------- - - b---------------------- --------------------------------- 1 d z Final Inspection b N_-�A ---------------------------------------Date _.- -- p Y SAN JOAQUIN LOCAL HEALTH DISTRICT E. H. 9 1-'68 Rev. 5M '